Meeting Rep Op Research Malaria Elimination May2014

Planning meeting for operational research

on malaria elimination 17–18 October 2013, Geneva, Switzerland Meeting Report | Global Malaria Programme

Planning meeting for operational research

on malaria elimination 17–18 October 2013, Geneva, Switzerland Meeting Report | Global Malaria Programme

© World Health Organization 2014

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Planning meeting for operational research on malaria elimination | iii

Contents

Background ............................................................................................................................ 1

The WHO/GMP operational research landscaping exercise .................................................. 1

OR priorities of partners ........................................................................................................ 2

Discussion on operational challenges for malaria elimination .............................................. 5

Identification of priority OR questions .................................................................................. 5

Recommendations from the meeting to WHO ...................................................................... 7

For further information please contact ................................................................................. 7

List of participants.................................................................................................................. 8

1 | Planning meeting for operational research on malaria elimination

Background

In the past decade, large-scale funding and the development of improved technologies and strategies have resulted in impressive improvements in malaria control and this in turn has led to renewed attempts at malaria elimination in a number of countries. The Global Malaria Action Plan (GMAP, 2008) reflects this ambition: “at least 8–10 countries … will have achieved zero incidence of locally transmitted infection by 2015.”

Moving forward with elimination requires adjustments to the way national malaria pro-grammes operate. For example, the strategies for case detection and surveillance are radi-cally different in control and elimination programmes. Countries may face constraints or bottlenecks as they make the transition from control to elimination, and operational re-search can help to remove these bottlenecks, thereby enabling countries to make the transi-tion from control to elimination phases more rapidly.

As part of WHO's work on accelerating countries’ transition from malaria control to malaria elimination, and supported by the Bill & Melinda Gates Foundation, WHO/GMP organized a planning meeting for operational research on malaria elimination on 17–18 October 2013. The meeting was held in Geneva, Switzerland, and was attended by 40 participants, includ-ing representatives from selected malaria-endemic countries, WHO regional offices, re-search institutes and funding partners.

The main objectives of the meeting were to:

• review the malaria operational research landscape;

• identify operational challenges, bottlenecks and priority research questions in the transition from malaria control towards elimination; and

• reach agreement among the meeting participants on the next steps, roles and respon-sibilities.

The WHO/GMP operational research landscaping exercise

Operational research (OR) has been defined as “the search for knowledge on interventions, strategies, or tools that can enhance the quality, effectiveness, or coverage of programmes in which the research is being done”.

To prioritize areas for future OR related to malaria elimination, WHO/GMP presented a re-view of published and ongoing OR for discussion at the meeting. This OR landscaping exer-cise included (1) a literature review of 515 malaria projects that met the definition of OR and had been published in the five years from January 2008 to June 2013; and (2) a partial sum-mary of ongoing OR based on information gathered from research institutes and funding partners, including the Bill & Melinda Gates Foundation (B&MGF), the President’s Malaria Initiative (PMI), the Global Health Group/ Malaria Elimination Initiative (GHG/MEI), the Asia Pacific Malaria Elimination Network (APMEN), the Malaria Eradication Scientific Alliance (MESA), and the Malaria Control and Evaluation Partnership in Africa (MACEPA).

The OR landscaping exercise revealed an extensive and active involvement of funding part-ners and research institutes in malaria OR. The activities were related to various program-matic areas including diagnosis, treatment, prevention, vector control, surveillance, epide-miology and transmission, health systems and cost-effectiveness.

Planning meeting for operational research on malaria elimination | 2

The OR landscaping exercise also identified the following constraints:

1. OR made up only a small number of all articles on malaria research published in the past five years. This implies that OR needs to be enhanced and researchers should be encouraged to publish their findings.

2. Few of the OR projects were led by the national malaria programmes which are re-sponsible for the implementation of control and elimination activities and have inti-mate knowledge of the real situation and the bottlenecks in their own programmes. This might indicate a need to further involve national malaria programmes in the im-plementation of OR and to strengthen OR capacity in malaria-endemic countries.

3. Although a number of OR studies are now looking at issues such as so-called hot spots, reactive case detection and asymptomatic parasite carriers, not many of them are be-ing conducted in countries that are engaged in malaria elimination. In the past five years, very few published OR projects focused on topics and activities relevant to ma-laria elimination. This may suggest that more OR is needed on such topics.

4. Low-transmission settings pose challenges for research studies that require large numbers of cases. OR in low-transmission settings will need to employ methods that work well with small numbers of cases, e.g. case-control studies.

Limitations to the methodology used to conduct the literature search were also identified, and suggestions were put forward to improve the OR landscape:

1. There was probably bias due to the search strategy. The literature review was limited to research cited in PubMed, which is normally undertaken by research institutes, while OR undertaken by national malaria programmes for improving programme management may not have been published.

2. Only English-language publications were reviewed; as OR projects may have been preferentially published in local languages, it is also necessary to search non-English publications.

3. Information on ongoing projects was only partial as it was only collected from some partners; more information about such projects should be collected from malaria-endemic countries.

A full report of the OR landscaping exercise will be made available in due course.

OR priorit ies of partners

The partner agencies and research consortia that participated in the meeting were invited to present their OR priorities and activities focused on malaria elimination. Most presented only their current OR activities, as the research priorities for the future are still under con-sideration and will take this meeting’s results into account.

Bill & Melinda Gates Foundation (B&MGF)

B&MGF aims to accelerate malaria elimination efforts (“Accelerate to zero”) by fostering coordination and collaboration among grant recipients and other partners on the following priority topics:

• diagnostic tests and infection mapping to enable elimination campaigns;


• drugs and delivery strategies for complete cure at individual and population levels;

• drugs, vaccines and vector control to reduce and block infection transmission;

• proof that we can accelerate the path towards and achievement of malaria elimina-tion with existing tools;

• policy and practice change to move more countries towards elimination;

• mobilizing sufficient resources;

• preparing for the endgame.

B&MGF has supported partners such as MACEPA, the Clinton Health Access Initiative (CHAI), GHG/MEI and malaria-endemic countries in OR related to vector control and treatment strategies, among others. It is also developing a new OR agenda with priorities focusing on malaria elimination issues.

Clinton Health Access Initiative (CHAI)

CHAI primarily supports national malaria control programmes (NMCPs) to make evidence-based decisions and optimize the impact of limited resources, focusing on:

• forecasting and modelling for decision-making;

• cost efficiencies and resource allocation;

• how best to scale up laboratory-confirmed diagnosis;

• managing parasite movement; and

• asymptomatic infections.

CHAI is actively involved in OR activities that answer programmatic questions in selected endemic counties. Examples include:

• mapping and modelling to suggest feasible operational plans to achieve elimination in the short term;

• identifying optimal delivery channels for seasonal chemoprevention (mass drug deliv-ery) in Nigeria;

• improving passive surveillance for maximum impact in Zimbabwe;

• combining routine surveillance data with mobile phone collected data to improve tar-geting of interventions in Namibia;

• testing reactive infection detection strategies and identifying asymptomatic infections in Swaziland, jointly with GHG/MEI.

Global Health Group/Malaria Elimination Initiative (GHG/MEI)

GHG/MEI presented its research priorities in:

• reactive case detection;

• primaquine roll-out;

• identification of risk factors; and

• response to hotspots and hot-pops.

GHG/MEI’s current and future projects include:

• production of a set of background papers on selected key challenges in malaria elimi-nation: importation, surveillance, management, mass drug administration (MDA) and financing;


• continuation of the primaquine work;

• implementing network studies to examine imported malaria;

• trialling targeted parasite elimination; and

• identifying strategies to incorporate private sector reporting into surveillance.

Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund)

The Global Fund does not set research agendas, but funds OR mostly though its monitoring and evaluation (M&E) budgets for country malaria programmes. Its priorities for funding are: OR that alleviates bottlenecks that impede successful programme implementation, with clear translation into action, and short time-frames. The programme must plan for the ca-pacity to design, implement, analyse and interpret the findings of the OR studies.

In addition, The Global Fund will continue to ensure that funding is available for routine sur-veillance, including therapeutic efficacy studies and insecticide-resistance monitoring.

Malaria Control and Evaluation Partnership in Africa (MACEPA)

MACEPA primarily supports African countries to scale up existing proven interventions and to document progress and impact, but also pays attention to malaria elimination in countries that aspire to this goal. Priorities for OR in the latter include, but are not limited to:

• malaria in mobile and remote populations;

• public and private sector actions;

• community engagement, participation, ownership;

• measuring intervention outcomes; and

• documenting progress towards zero local transmission.

Malaria Eradication Scientific Alliance (MESA)

MESA seeks to advance the science of malaria eradication, and supported its first round of grants to OR on health systems’ readiness and measurement of transmission last year. The second round of grants will focus on OR priorities as determined at this meeting. A call for proposals was planned for the end of October 2013.

Special Programme for Research and Training in Tropical Diseases (TDR)

TDR currently collaborates with WHO/GMP and the WHO/Regional Office for Africa inter-country support team in Southern Africa (IST) on OR capacity building for malaria elimination. A first workshop was held in Harare, Zimbabwe in October 2013 to identify priority areas for OR around malaria elimination activities, including research studies that could be conducted immediately using routinely-collected (or previously-collected) data. Studies using available data will be the basis of a Structured Operational Research and Training Initiative (SORT IT) programme. SORT IT programmes take participants through the entire OR process from the formulation of a research question to writing a paper for peer-reviewed publication and preparation of an evidence brief for consideration by policy-makers. Programmes consist of three one-week workshops, held over a 10-month period. Workshop facilitators continue to provide mentorship to participants between workshops.


Each workshop addresses different stages of the research process:

1. research questions, protocol development and ethics; 2. data management and data analysis; 3. paper writing, peer review and policy implications.

This SORT IT programme is scheduled to start in August/September 2014 in four southern African countries: Botswana, Namibia, South Africa and Swaziland. The report of the 2013 Harare meeting is being prepared for publication in a relevant peer-reviewed journal.

Discussion on operational challenges for malaria elimination

Following the presentation of the OR landscape and presentations from the partners, the meeting participants had an intensive discussion on operational challenges and bottlenecks in the transition from malaria control to elimination. The discussion centred on the following observations:

• Major epidemiological shifts are being observed as countries progress towards malar-ia elimination. Imported malaria is gaining more prominence and cases are increasing-ly reported in adult men, clustered geographically, and among migrants and other hard-to-reach groups.

• Essential surveillance data to guide policy-makers in moving from control to elimina-tion is inadequate and incomplete in countries with poor health systems. There are difficulties in integrating the malaria information from private-sector health providers into the health information system.

• Sustainability and phase-out of vector control interventions in low-transmission set-tings where financial support from donors is waning, need to be addressed.

• Innovative approaches are necessary to address potential changes in vector behaviour, including selection for outdoor biting and increased biting during crepuscular periods, which will limit the effectiveness of long-lasting insecticidal nets (LLINs) and indoor re-sidual spraying (IRS).

• There is an increasing need for accurate detection of asymptomatic infections and mi-cro-parasitaemic infections as transmission is being reduced.

• Low compliance with the 14-day primaquine course for radical cure of Plasmodium vivax infections and the safety of single dose primaquine for P. falciparum in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency need to be addressed.

• Insufficient OR capacity of malaria control programmes needs to be addressed.

The meeting participants noted that funding and collaboration for OR will be pivotal to sus-tain current progress towards malaria elimination.

Identif ication of priority OR questions

The process for identification of priority OR questions adopted at this meeting included three steps based on group discussion and individual voting. Participants were assigned to one of three groups (classified as Group-Pf, Group-Pv and Group-island) according to the different malaria profiles of the countries assigned to the particular group. Each group con-


sisted of country representatives, research institutes and partners. At least 10 specific re-search questions were identified from each group discussion in step 1. These questions were then consolidated with those identified before the meeting and 17 out of 43 research ques-tions were finally prioritized by group discussions in step 2. Ranking based on individual vot-ing was conducted to obtain consensus on a list of priority questions in step 3, ranging from high to lower priority, as shown in Box 1.

Box 1. Priority research questions for accelerating programme transition towards malaria elimination, ranked from high (1) to lower (17) priority

1. What is the optimal vector control strategy for elimination? a. full coverage or focal coverage? b. both IRS and insecticide-treated nets/LLIN or one or the other alone, and what is the optimal combination? c. when will vector con-trol interventions be phased out?

2. What are the optimal strategies for identifying and providing services in sup-port of elimination among a range of mobile and remote groups?

3. How can malaria foci be identified and responded to?

4. What are effective and feasible strategies for ensuring quality case-management and engagement in case reporting in the private sector?

5. What diagnostic technologies should be used for detecting submicroscopic infections?

6. How can community engagement for malaria elimination be improved?

7. What is the optimal MDA strategy (i.e. timing, combinations of drugs, num-ber of rounds, duration, geographically and demographically defined at-risk population, adverse events monitoring, and population acceptability)?

8. What strategies should be used to differentiate indigenous and imported cases?

9. How can primaquine be effectively deployed for interrupting transmission of P. falciparum in pre-elimination and elimination settings?

10. What are the main barriers to data reporting and what strategies could be used to improve the speed and quality of reporting?

11. What is the optimal intervention where outdoor biting is prevalent?

12. How can primaquine safety be monitored in the absence of G6PD testing?

13. How can receptivity and vulnerability of border areas be evaluated?

14. Where and when is environmental management appropriate?

15. What is the most efficient radius for reactive case detection and intervention around the home of the passively detected case?

16. How can microscopy skills and quality assurance be sustained in low-transmission settings?

17. When and where are larviciding measures appropriate and what is the im-pact of larviciding on malaria transmission?.


Recommendations from the meeting to WHO

1. WHO/GMP will develop an OR agenda in discussion with partners such as B&MGF, the Global Fund and TDR. The agenda will specify target countries, financial resources, and desired linkages between NMCPs, research institutes and partners. All of the 17 priority research questions should be included on the agenda for selective adoption by different countries, research institutes and partners. Attention will be paid to iden-tification of OR priorities specific to particular countries.

2. WHO/GMP will develop an OR work plan for targeting countries with specific research questions, to accelerate countries’ transition from malaria control to elimination.

3. WHO/GMP and TDR will expand the SORT IT approach, developed in Southern Africa, to other groups of countries, assuming availability of funds.

4. WHO regional offices will collect information on published and ongoing OR projects from relevant countries for continually improving the OR landscape.

For further information please contact

Strategy, Economics and Elimination Team (SEE) Global Malaria Programme World Health Organization Email: [email protected] www.who.int

http://www.who.int/


List of part icipants

African Region

Dr L. Mazhani University of Botswana School of Medicine Private Bag 0022 Gaborone, Botswana

Mr J. Alcantara National Malaria Control Programme (NMCP) Ministerio da Saúde BP 23 São Tome et Principe

Dr M. Santos National Malaria Control Programme (NMCP) Ministerio da Saúde BP 23 São Tome et Principe

Mr M. Msellem Medical Laboratory Scientist Ministry of Health P O Box 503 Zanzibar, United Republic of Tanzania

Mr S. Ame Public Health Laboratory Ivode Carneri P O Box 122 Chake-Chake, Pemba, United Republic of Tanzania

Region of the Americas

Ms M. Eersel Ministry of Health Paramaribo, Suriname

Mr S. Vreden Foundation for Scientific Research Paramaribo, Suriname

South-East Asia Region

Dr W. Satamai Bureau of Vector Borne Diseases Department of Disease Control Ministry of Public Health Nonthaburi 11000, Thailand

Professor P. Singhasivanon Mahidol University Faculty of Tropical Medicine Mahidol University 420/6 Rajvithee Road Bangkok, 10400, Thailand

Dr K. Mendis Colombo, Sri Lanka (unable to attend)

Western Pacific Region

Mr X. Zhuigui National Institute of Parasitic Diseases 207 Rui Jin Er Road Shanghai 200025, People’s Republic of China (unable to attend)

Mr G. Taleo National Malaria Control Programme (NMCP) Health Department PMB 9009 Port Vila, Vanuatu (unable to attend)

Dr L. Dysoley National Center for Parasitology Entomology and Malaria Control St 322 and Monivong Phnom Penh, Cambodia

European Region

Professor V.P. Sergiev Director, Martsinovsky Institute of Medical Parasitology and Tropical Medicine Malaya Pirogovskaya Street 20 119435 Moscow G.435, Russian Federation

Dr A. Velibekov Deputy Minister of Health, Ministry of Health 1 M. Mirgasimov Street AZ 1022, Azerbaijan

Eastern Mediterranean Region

Dr F. Ali National Malaria Coordinator Khartoum, Sudan

Dr A. Ghouth Hadranmout University Department of Community Medicine Yemen

International Institutes

Dr P. Alonso Institute for Global Health Barcelona (ISGLOBAL) Barcelona, Spain (unable to attend)

Dr M. Colenar University of Liverpool Liverpool, England (unable to attend)


Dr J. Cox DrPH Course Director Faculty of Infectious and Tropical Diseases London School of Hygiene and Tropical Medicine London, England

Dr M.A. Chang US Centres for Disease Control and Prevention Atlanta, Georgia United States of America (unable to attend)

Dr H. Sturrock Global Health Group University of California San Francisco United States of America

Dr M. Tanner The Swiss Tropical Research Institute Basel, Switzerland (unable to attend)

Dr J. Utzinger The Swiss Tropical Research Institute Basel, Switzerland (unable to attend)

Dr R. Dhiman National Institute of Malaria Research New Delhi, India

Dr K. Whitfield Malaria Eradication Scientific Alliance (MESA) – Barcelona Centre for International Health Research Barcelona, Spain

Partners

Dr D. Measham Bill & Melinda Gates Foundation (B&MGF) United States of America

Dr T. Kanyok Bill & Melinda Gates Foundation (B&MGF) United States of America

Dr J. Cohen Clinton Health Access Initiative (CHAI) United States of America

Dr A.L. Menach Clinton Health Access Initiative (CHAI) United States of America

Dr A. Ramsay Special Programme for Research and Training in Tropical Diseases (TDR) Geneva, Switzerland

Dr S. Filler The Global Fund Geneva, Switzerland

Dr R. Steketee Malaria Control Program and Malaria Control and Evaluation Partnership in Africa (MACEPA) PATH/USA

WHO Regional Offices Dr A. Kalu Regional Office for Africa (unable to attend)

Dr I. Sanou Regional Office for Africa

Dr R. Escalada Regional Office for the Americas

Dr G. Zamani Regional Office for the Eastern Mediterranean

Dr E. Gasimov Regional Office for Europe

Dr A. Valibayov Regional Office for Europe

Dr L. Ortega Regional Office for South-East Asia

Dr L. Vestergaard Regional Office for the Western Pacific

WHO Headquarters Secretariat Dr R. Newman WHO/Global Malaria Programme (GMP)

Dr R. Cibulskis WHO/Global Malaria Programme (GMP)

Dr P. Ringwald WHO/Global Malaria Programme (GMP)

Dr A. Rietveld WHO/Global Malaria Programme (GMP)

Dr S. Zhou WHO/Global Malaria Programme (GMP) (Meeting organizer)

Dr M. Velarde WHO/Global Malaria Programme (GMP)

Ms S. Tabengwa WHO/Global Malaria Programme (GMP) Administrative Assistant

Planning meeting for operational research on malaria elimination. Meeting report,

17–18 October 2013, Geneva, Switzerland

Global Malaria ProgrammeWorld Health Organization

20 avenue Appia1211 Geneva 27

Switzerland

WHO/HTM/GMP/2014.5

Meeting Rep Op Research Malaria Elimination May2014

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